The notices are plastered on lampposts and rubbish bins in city centres and near tertiary institutions. Among offers of penis-enlarging cream, refrigerator repairs and DStv installations, there are "quick same-day abortion" or "same-time abortions guaranteed, plus free cleaning.
Female doctor." They bear only cellphone numbers and promise to be "quick and pain-free".

Quick the abortions may be; after all, how long does it take to hand over a few tablets? Safe? That depends on a range of factors, including the stage of pregnancy and the woman's general health – questions rarely asked and tests rarely, if ever, offered. Expensive? Oh yes.

But for many desperate young women who do not know where else to turn, these backstreet abortionists seem to be the only answer.

Many of the women who respond to these notices do not know that under South African law they are entitled to a termination of pregnancy free of charge at a registered health institution and that their local clinics or hospitals should either perform the termination or refer them to one that has the facilities. Failing that, for a fee there are clean, safe family-planning clinics throughout South Africa – Marie Stopes clinics and others – that offer, in addition to terminations, pre- and post-procedure counselling, a recovery room and follow-up visits.

The law is clear: the 1996 Choice on Termination of Pregnancy Act states that it "promotes reproductive rights and extends freedom of choice by affording every woman the right to choose whether to have an early, safe and legal termination of pregnancy according to her individual beliefs".

Non-mandatory and non-directive counselling
A pregnancy may be terminated on request during the first 12 weeks of pregnancy, according to the law. After the first trimester, but up to and including the 20th week, the pregnancy can still be terminated "if a medical practitioner, after consultation with the pregnant woman", believes that continuing it risks injuring the woman's physical or mental health if there is a "substantial risk" that the foetus is suffering a severe physical or mental abnormality, if the pregnancy resulted from rape or incest, or if continuing the pregnancy would significantly affect the woman's social or economic circumstances.

After the 20th week, it takes two medical practitioners or a doctor and a registered midwife who has completed a prescribed training course to agree that continuing the pregnancy would endanger the woman's life or result in a severely malformed or injured foetus.

The law specifies that surgical terminations may take place only at facilities designated by the health minister. It recommends that the state promote non-mandatory and non-directive counselling, both before and after the termination.

A 2004 amendment allows provinces to designate facilities for termination of pregnancy services.

Thirty-eight clinics are registered to provide terminations and 174 hospitals – several in every province – have been designated as such service providers. In four provinces – KwaZulu-Natal, Mpumalanga, Free State and Northern Cape – women who wish to terminate their pregnancies must go to a hospital. But in Gauteng there are 12 clinics and 25 hospitals designated to perform the service. Limpopo has 10 clinics and 31 hospitals, the Western Cape has five clinics and 31 hospitals, the Eastern Cape has three clinics and 27 hospitals and in North West there are 10 clinics and 14 hospitals.

The criteria are tough, including everything from telephones to transport, appropriate surgical and emergency equipment and access to an emergency referral centre.

Designated facilities
But being a designated provider does not necessarily mean providing the designated services. According to Marion Stevens, a midwife and co-ordinator for Women in Sexual and Reproductive Rights and Health, South Africa's abortion services are "completely inadequate. Only 40% of designated facilities are operational."

According to Stevens, one needs trained staff and administering a medical abortion is not recognised as an occupational-scarce skill, for which there is usually extra pay. Becoming an HIV nurse is considered more praiseworthy in the community than terminating unwanted pregnancies and HIV nurses receive the scarce-skills allowance.

In fact, she said: "Nurses should be trained in comprehensive sexual and reproductive healthcare, which includes being able to provide antiretroviral medicine as well as handing out medical-abortion tablets, which is part of the ambit of prevention of mother-to-child transmission of HIV, focal point two in preventing unintended pregnancies.

"Only the Western Cape has developed medical guidelines for abortion and only the Western Cape has publicised the location of public hospitals and clinics that will perform them. The rest of the country is implementing medical abortion in an ad-hoc fashion in research sites and where districts have taken the initiative. The national health department is not championing these services for women."

The South African Health Review's 2011 issue quotes an unnamed chief director who told researchers that "there are managers in our health system who do not support the providers of abortions. Often, the provider is put somewhere near the mortuary in a hospital, somewhere out of view. There is a lot of marginalisation and stigmatisation."

The department of social development is conducting extensive research into adolescent sexual and reproductive health and rights. Among its findings so far is that the percentage of 18-year-olds who have had sex is 51.9%, much higher than teenagers even a year younger, an age group in which only 39.7% said they had had sex. Boys, of course, claim a higher percentage of sexual encounters.

Legalisation of abortion
Yet teenage fertility is decreasing, a situation that could be attributed to the legalisation of abortion – the number of terminations among women 18 years or younger increased to 14.6% in 2009. Legal abortions in public facilities rose in 2011 by close to 25% to 77&nbsp;771, but only 1&nbsp;380 in these registered institutions were for women under 18, according to a health department response to a question in Parliament in August.

In March, 20-year-old University of Johannesburg student Ayanda Masondo was found dead in her room, a suspected victim of a botched abortion.

Why would anyone resort to backstreet abortionists – who dish out pills meant for only the first 63 days, ask no questions and do no follow-up – when there are safer ways to terminate pregnancies?

There is a lot of ignorance. Too many young women believe abortion is still illegal – as many as one-third of the female population.

"Even in cases where people might be aware of the [termination of pregnancy] law we have a big problem with service availability," said Naomi Lince, director of the non-governmental organisation Ibis.

"Abortion is still unfortunately a stigmatised issue in South Africa. For young women, there is a double stigma: they are young, not married, not supposed to be having sex and then they need an abortion.

Challenges
"Some young women are persistent and will go to services and will leave [only when] they get what they came for, but many of them experience challenges when they go to the clinic not only in asking for an abortion, but in gaining access to contraceptives."

Ibis looked at young women attending services at three clinics in Soweto. They talked to people in the surrounding community as well as to clinic nurses. "We focused on healthcare providers in reproductive health services at the clinic: HIV, abortion and antenatal care.

"What we heard from the young women was that they were often turned away or scolded for asking about sex and sexuality and for services related to that – contraception, abortion, even antenatal care.

"There were a few nurses who had a positive attitude and were there to help, but the majority felt the young women should abstain."

There are no figures for the numbers of women dying lonely deaths at home, in shacks or in university residences after botched abortions.

Health department figures cover deaths in public facilities and highlight the fact that 25.7% of avoidable maternal deaths between 2005 and 2007 were caused by unsafe abortions, a rise of 4.5% on the previous three years. The department's Saving Mothers report, released in 2012, notes that, at 4&nbsp;867, more maternal deaths from a variety of causes were reported in 2008 to 2010 than in any previous similar period.

National priority
In its 2011 South African Health Review, the Health Systems Trust notes: "Despite the provision of free maternity care, high rates of antenatal-care coverage and delivery by skilled birth attendants, legal abortion and a system of confidential inquiries to assess maternal deaths, indicators of maternal health reveal persistent systemic problems in the South African public health sector." The review adds that "the government has made decreasing maternal deaths a national priority".

Millennium development goal number five, set for 2015, calls for a reduction in the maternal mortality rate to 38 per 100 000 live births. At 310 per 100 000, the South African rate is much better than Africa's as a whole – between 500 and 1500 per 100&nbsp;000 – but it is far more than the millennium goal.

The incidence of HIV among pregnant women is a huge complicating factor. The health department's Saving Mothers reports over the past decade have highlighted "non-pregnancy-related infections, mainly Aids" as responsible for 50% of maternal deaths and is taking steps to shrink that percentage.

The demand for terminations is likely to continue to rise in the foreseeable future. In its second South African National Youth Risk Behaviour Survey (2008), the Medical Research Council surveyed high-school pupils to determine what kind of contraceptives they used. Of the 3579 pupils surveyed, 45.1% had got the message about condoms, 4.7% used birth control pills, 7% used the contraceptive injection and 1.4% had used the morning-after pill, but the rest used withdrawal, other unspecified methods or nothing at all. The use of condoms seemed to increase as the youngsters aged – from 21.1% among 13-year-olds to 50.6% among 18-year-olds.

With so much left to chance, pregnancies are sure to follow. The council asked how many had had a termination, or the number whose partner had undergone the procedure and where they had gone for it.

They found that 51.5% had gone to a hospital or clinic for the procedure, but the rest had gone to a traditional doctor or healer, or "another place".

Access to contraception
"There is a huge commitment from the health minister to improve access to contraception," said Marie Stopes's Sarah Osman, "and it is looking at a new module for school health programmes. Teenagers at school should have access to contraception. There was so much focus on the HIV epidemic and on condoms, but very little on other sexual and reproductive health issues. That is becoming a priority again."

A number of non-governmental organisations are trying to educate and empower young women.

In Gauteng, for example, Lifeline Johannesburg's Girls on the Move programme in its first year has reached close to 2 000 pupils in grades seven and eight. Working in schools in Alexandra and Soweto, facilitators run training sessions ranging from looking at beliefs and values about gender and sexuality to common methods of contraception and biology lessons on male and female reproductive systems.

In one module, the girls are handed an egg to keep safe in order to begin to understand what it means to be a parent and there are modules on HIV and other common sexually transmitted infections.

"I gained," said one young participant, "that younger teenagers must not rush things that are bigger than their eyes, like sex, alcohol, drugs and smoking dagga."

"I learned that it is not easy to raise a child as a teenager," said another.

Capacity
And, said a third: "I gained a lot of things from Girls on the Move; for example, I have a right to say 'no'."

The courses are so popular that Lifeline has been asked to run them for boys as well in the schools where they are presented.

Chiva South Africa, based in KwaZulu-Natal, concentrates on HIV and access to antiretrovirals. Its programme aims to build the capacity among KwaZulu-Natal health professionals to deal with adolescents' physical and psychological issues. The organisation has devised workshops and seminars for doctors, nurses, pharmacists, dieticians, counsellors and other professionals with subjects such as facility-based action plans and the impact of HIV on emotional, cognitive and social development. Chiva's statistics show HIV prevalence at 13.7% among women between the ages of 15 and 24 and at 4% among men of the same age and finds HIV-negative adolescents – which it defines as those between 10 and 19 – the group most vulnerable to HIV infection.

Ibis has devised a three-day workshop for providers, including "values-clarification sessions" on how providers' beliefs might affect their ability to do their job. It has worked with a sex therapist to develop a module focusing on nurses' experiences when they were young to help them to understand the young women who come to the clinics. It also runs practice sessions on how to talk about difficult issues.

It is planning to take the workshops to Limpopo and eventually ­farther afield.

Disrespect for authority
It will not be easy to change minds. Ibis's research in Zola, Soweto, showed that community members were even more harshly judgemental than nurses. Among the root causes of teenage pregnancy and HIV identified by community stakeholders and parents were "disrespect for authority, multiple partners, transactional sex, intergenerational relationships, a desire for a flashy lifestyle, alcohol and drug abuse, a preponderance of taverns, poor information about sex, low family-planning use, lack of parental guidance, overexposure to sexual imagery in the media and rampant poverty".

Said Sexual Health and Rights Initiative South Africa director Betsi Pendry: "One of the obvious challenges is that it is culture and value driven and this takes a long time to shift. While laws can be changed, teaching people new ways of understanding, seeing, believing and ­acting takes much longer and it ­happens through cultural shifts, not just legal shifts.

"South Africa is a country that straddles traditional and modern viewpoints next to and within each other. We believe that if we root our understanding and practices in enhancing freedom, dignity and equality in the school, the home, at work, in the clinics, in our relationships and between people as a daily undertaking, the traditional and the modern can come together to create a culture that embodies sexual and reproductive health and rights and the possibility for growth and development."

Barbara Ludman is a freelance journalist and wrote this article on behalf of Sharisa (Sexual Health and Rights Initiative South Africa).